Elaine D. Eaker

The risk of acute myocardial infarction after oestrogen and oestrogen‐progestogen replacement

Objective To determine the relative risk of developing a first acute myocardial infarction after treatment with oestrogens alone or oestrogen‐progestogen combinations.

Coronary artery disease and coronary artery bypass grafting in diabetic patients aged ≥65 years (report from the Coronary Artery Surgery Study [CASS] registry)

A cohort of 317 diabetic patients, aged > or = 65 years, with angiographically proven coronary artery disease, was analyzed and followed for a mean of 12.8 years. Compared with 1,843 age-matched nondiabetic patients, diabetic patients were more likely to (1) have a higher number of coronary occlusions, (2) not be current smokers, (3) have higher systolic but lower diastolic blood pressures, (4) have evidence of peripheral vascular disease, and (5) be women. They did not differ significantly with respect to total cholesterol, family history of coronary artery disease, history of hypertension, or left ventricular hypertrophy. In the total elderly cohort, diabetes was found to be an independent predictor of mortality, conferring a 57.0% increased risk of death. Survival analysis showed that diabetic subjects consistently had higher mortality than nondiabetics. However, the relative survival benefit of coronary artery bypass graft surgery versus medical therapy was comparable in diabetic and nondiabetic patients. Surgical therapy conferred a reduction in mortality of 44%.

A Measure of Perceived Burden among Caregivers

This, report describes an easily administered scale for measuring perceived burden among caregivers offamily members with dementia. During home interviews conducted in 1991, 82 caregivers rated theirfamily member with dementia on several items related to functional ability, the type of care provided, and associated stress. The resulting measure ofperceived burden, based on 15 internally consistent items (alpha = 0.87), is significantly correlated with depressive symptomatology (r = 0.38, p = 0.0004). This measure is useful in assessing perceived stress associated with specific caregiving responsibilities. It can be used, along with other measures of patientfunctional status, to assess overall caregiver burden and to target intervention strategies.

Community intervention and trends in dietary fat consumption among black and white adults

OBJECTIVE This study assessed whether a state public health department could effectively implement an affordable nutrition intervention program at the community level. DESIGN Cross-sectional data were collected via telephone surveys of 9,839 adults, aged 18 years or older, in 1987, 1989, and 1991 in two South Carolina communities. Nutrition education programs began in 1988 in one community. The other community served as a comparison site. We assessed and compared changes in community levels of dietary fat and weekly meat consumption, salt use, and nutrition promotion awareness with analysis of covariance regression techniques that included race, sex, and age as covariates. RESULTS We observed favorable changes in most eating behaviors and levels of awareness in both communities. The intervention community experienced greater absolute changes that the comparison community in use of animal fats (-8.9% vs -4.0%; P = .02) and liquid or soft vegetable fats (+8.4% vs +3.6%; P = .04), and in awareness of restaurant nutrition information (+33.0% vs +19.4%; P = .0001). Although the primary type of dietary fat used differed between black and white respondents, we observed significant change among both groups. CONCLUSIONS These results suggest that community-wide nutrition education programs may have augmented regional or national changes in dietary behavior among white and black adults in the intervention community.

Coronary Artery Disease in Women

D iseases of the heart are the leading cause of death among women in the U.S. and account for about 28% of all deaths in women. Of the 550,000 people who die each year in the U.S. from heart-related diseases, >250,000 are women. Because coronary artery disease [CAD] is less common in women, it has not been as thoroughly studied in women as in men. Results from studies of men have frequently been generalized to women, which may not be appropriate. The National Heart, Lung, and Blood Institute Workshop on Coronary Heart Disease in Women, held in Bethesda, Maryland, January 26 to 28, 1986, convened scientists from the disciplines of epidemiology, atherosclerosis and clinical cardiology who have studied or have access to data about CAD in women. The workshop was designed to delineate the current state of knowledge about CAD in women and to define issues and questions that need further study, areas where information is lacking and needs and opportunities for research. Three aspects of CAD in women were discussed: (1) epidemiologic data on the prevalence and risk of fatal and nonfatal CAD, (2) pathophysiologic processes of atherogenesis that may be unique to women and (3) clinical aspects of CAD in women. The following is a summary of the workshop deliberations in each of these areas.

Frequency of uncomplicated angina pectoris in type A compared with type B persons (the Framingham study)

The impact of type A behavior on coronary artery disease was examined in 570 men and 719 women based on 20 years of follow-up in the Framingham Study. A comparison of type A and B persons showed similar levels of systolic blood pressure, total and high density lipoprotein cholesterol and body mass index. Behavioral status also was unrelated to diabetes, cigarette smoking and alcohol intake. Despite similar cardiovascular risk profiles, type A behavior was associated with more than a 2-fold excess risk of angina pectoris, uncomplicated by other symptoms of coronary artery disease (p less than 0.05 for men and p less than 0.01 for women). Type A behavior, however, was not related to an increased risk of myocardial infarction and fatal coronary events. Among the victims of uncomplicated angina, the risk of subsequent coronary morbidity and mortality in both type A and type B men and women increased by more than 4-fold (p less than 0.001). Although the risk was reduced among type A persons, it was not statistically significant. It is concluded that uncomplicated angina pectoris occurs with greater frequency in type A persons than in those who are type B, without explanation by concomitant risk factors. In addition, the prognosis for myocardial infarction and coronary artery disease mortality in angina patients classified as type A is as serious as the prognosis for those who are type B.

Ethnic differences in the burden of caregiving

Family caregivers of dementia patients experience varying levels of burden (or stress) associated with care giving tasks. Although this burden may lead to negative health effects for caregivers, very few studies have focused on ethnic differences in the correlates of perceived burden. In a pilot study, we examined correlates of perceived burden associated with providing care for a family member with dementia among African-American (n=20) and white (n=62) caregivers. In this limited sample, we found that mean burden scores were increased among whites if they were the spouse of the patient, and among African-Americans if annual family income was in excess of

Coronary Artery Disease in Diabetic Patients With Lower-Extremity Arterial Disease: Disease Characteristics and Survival: A report from the Coronary Artery Surgery Study (CASS) registry

20,000. We found no mean burden score differences for either group by past use of a variety of services. Although these results are preliminary, this ongoing study has the potential to provide needed information on sources and correlates of perceived burden among rural African-American and white caregivers.

The association of positive and negative events with depressive symptomatology among caregivers

OBJECTIVE Patients who have diabetes and lower-extremity arterial disease (LEAD) are at an increased risk of dying from coronary artery disease (CAD). This study was undertaken to: 1) define the clinical and arteriographic factors associated with LEAD among diabetic patients; 2) determine the long-term survival and predictors of mortality of diabetic patients with LEAD, compared to those without LEAD; and 3) determine if the presence of LEAD is an independent risk factor for mortality among diabetic patients with CAD. RESEARCH DESIGN AND METHODS A total of 263 diabetic patients from the Coronary Artery Surgery Study (CASS) registry with LEAD, who were ≥ 50 years of age, and who had arteriographically proven CAD, were identified and followed for a mean of 12.8 years. A total of 1,349 comparably aged diabetic patients from the CASS registry with CAD and no evidence of LEAD were followed for an equivalent period of time. RESULTS Compared with diabetic patients without LEAD, diabetic patients with LEAD were characterized by the presence of cerebrovascular disease, a high rate of current smoking, elevated systolic blood pressure, high grades of angina pectoris, and digitalis use. Severity of epicardial CAD and extent of CAD were not independent predictors of the presence of LEAD. On follow-up, diabetic patients with LEAD had significantly higher mortality (mostly cardiovascular) than diabetic patients without LEAD, with a median survival of 8.1 and 10.9 years, respectively. On multivariate analysis, age, the number of significantly narrowed coronary arteries, and the presence of left ventricular dysfunction predicted mortality in both subsets of diabetic patients. Among all the diabetic patients with CAD, the presence of LEAD was an independent risk factor for mortality. CONCLUSIONS Diabetic patients with LEAD have a higher mortality rate (mostly cardiovascular) than diabetic patients without LEAD, despite no apparent anatomic differences in the severity and extent of CAD. This suggests that factors associated with the presence of LEAD, other than the anatomy of the coronary circulation, may play a role in determining survival among diabetic patients with LEAD and CAD.

Psychosocial factors in the epidemiology of coronary heart disease in women

A pilot study of eighty-two caregivers was conducted in South Carolina in 1991 to identify positive and negative factors associated with caregiving. Through home visits, interviewers obtained data on a variety of physical and mental health measures, including two new scales designed to measure perceived “positive” and “negative” events that had occurred in the previous month. The Center for Epidemiologic Studies Depression scale was used as a measure of depressive symptomatology. For the new scales, only items that were significantly correlated with depressive symptomatology (p < 0.01) were retained. The new “positive” event scale (8 items) and the new “negative” event scale (16 items) had alpha coefficients of 0.79 and 0.86, respectively. These scales may be useful to researchers in sorting out mediating factors related to the burden of caregiving and in providing points for intervention.